A cardiac intimal sarcoma mimicking infective endocarditis

Primary malignant cardiac tumors are rare and usually misdiagnosed because they can mimic more common intracardiac lesions, therefore, in clinical practice it is important to always consider even uncommon diseases in order to avoid delayed diagnosis and to plan the most appropriate therapeutic strategy in a timely fashion. We report a case of a 73-year-old man with clinical signs and imaging findings (echocardiography) suggesting infective bacterial endocarditis of the mitral valve. However, intraoperative evaluation raised suspicion that the mitral lesions had a different nature. Surgical removal of the mass was performed, and the final correct diagnosis was made through pathologic examination, revealing a mitral valve sarcoma thus allowing for the beginning of specific oncological treatment.

Microinvasive mitral valve repair with transapical mitral neochordae implantation

Microinvasive cardiac surgery includes procedures performed off-pump, on the beating heart, with limited or absent skin incision, and those that rely on live imaging techniques. Transapical off-pump beating heart neochordae implantation allows the repair of severe mitral valve regurgitation due to leaflet prolapse or flail with live three-dimensional echo guidance. This procedure has shown good results for up to 5 years and can be considered as a valid alternative to conventional surgery in selected patients with high prediction of success based on clinical and anatomical considerations. The aim of this review is to describe the devices, indications, patient screening process, clinical and echocardiographic results, and future perspectives of this procedure.

Fast-Track Virtual Reality to Facilitate 3D Reconstruction in Congenital Heart Disease

OBJECTIVES

A limitation of the clinical use of 3D reconstruction and virtual reality (VR) systems is the relatively high cost and experience required to use hardware and software to effectively explore medical images. We have tried to simplify the process and validate a new tool developed for this purpose with a novel software.

METHODS

Five patients with right partial anomalous pulmonary venous return with adequate preoperative imaging acquired by magnetic resonance were enrolled. Five volunteers with no previous experience in the field of 3D reconstruction were instructed to use the software after a short video tutorial. Users were then asked to create a 3D model of each patient's heart with DIVA and their results were compared quantitatively and qualitatively with a benchmark reconstruction performed by an experienced user.

RESULTS

All our participants recreated 3D models in a relatively short time, maintaining a good overall quality (average quality score ≥ 3 on a scale of 1-5). The overall trend of all the parameters analysed showed a statistical improvement between Case 1 and Case 5, as users become more and more experienced.

CONCLUSIONS

DIVA is a very simple software that allows accurate 3D reconstruction in a relatively short time ("fast-track" VR). In this study, we demonstrated the potential use of DIVA by inexperienced users, with a significant improvement in quality and time after a few cases were performed. Further studies are needed to confirm the potential application of this technology on a larger scale.

Propensity-Weighted Comparison of Conventional Stented and Rapid-Deployment Aortic Bioprostheses

OBJECTIVE

Aim of this study was to compare early clinical and hemodynamic outcomes of Intuity and ME bioprostheses.

METHODS

A propensity score weighting approach was performed. Preoperative variables were defined according to EuroSCORE criteria and postoperative complications according to VARC-2 definitions.

RESULTS

We evaluated 375 patients who underwent SAVR with the two study devices. Intuity and ME were implanted in 252 (67.2%) and in 123 (32.8%) patients, respectively. There were no differences in terms of postoperative complications, including mortality (1% in each group; OR 0.46[0.05;4.21]). The incidence of pace-maker implantation was 6% and 5% in Intuity and ME groups, respectively (OR 0.53[0.27;1.07]). Intuity showed significantly lower gradients (Median mean gradients: 9mmHg vs. 14mmHg, p<0.001), larger effective orifice area index (1.13cm²/m² vs. 1cm²/m², p=0.007) and lower incidence of patient-prosthesis mismatch (7.1% vs. 22.8%, p=0.006).

CONCLUSIONS

The RD Intuity provides similar early clinical outcomes but shows significantly better hemodynamic performance compared to the ME valve.

Porcelain aorta: A surgical dilemma in orthotopic heart transplantation

BACKGROUND

Circumferential calcification of the ascending aorta, known as porcelain aorta, in a patient candidate to a heart transplant, requires technically demanding and high-risk procedural adjustments.

AIMS

This case report showed successful replacement of ascending aorta due to extensive calcification at time of heart transplantation.

MATERIALS AND METHODS

In the operating theatre, after median sternotomy, cardiopulmonary bypass (CPB) was achieved via the right femoral artery and vein. Due to the impossibility of replacing the ascending aorta using safe aortic cross-clamping, a moderate hypothermia was established, and circulatory arrest was realized. According to Kazui protocol for selective anterograde cerebral perfusion via anonymous trunk and left carotid artery, ascending aorta was replaced with vascular prosthesis.

RESULTS

Thanks to accurate pre-surgical planning, which included hypothermic circulatory arrest, ascending aorta replacement, before orthotopic heart implantation, we were able to perform the procedure successfully and prevent neurological events.

DISCUSSION

Although different reports showed the feasibility of heart transplant combined to aortic replacement for aneurysmatic pathology, few cases were described for porcelain aorta, due to technically demanding procedure and prohibitive aortic cross-clamping. To avoid vascular embolization, dissection and mural laceration, aortic cross-clamping is not recommended. We performed aortic replacement at first, to reduce allograft ischemia.

CONCLUSION

The use of hypothermic circulatory arrest technique with selective cerebral perfusion for aortic replacement, followed by vascular graft clamping to favour cardiac allograft implantation, could be considered a winning combination to guarantee procedural success and to reduce perioperative complications.